Effectiveness of Interventions for Adults With Psychological or Emotional Impairment After Stroke: An Evidence-Based Review

Mary W. Hildebrand

doi:10.5014/ajot.2015.012054

Abstract

This evidence-based review was conducted to evaluate the effectiveness of occupational therapy interventions to prevent or mitigate the effects of psychological or emotional impairments after stroke. Thirty-nine journal articles met the inclusion criteria. Six types of interventions were identified that addressed depression, anxiety, or mental health–related quality of life: exercise or movement based, behavioral therapy and stroke education, behavioral therapy only, stroke education only, care support and coordination, and community-based interventions that included occupational therapy. Evidence from well-conducted research supports using problem-solving or motivational interviewing behavioral techniques to address depression. The evidence is inconclusive for using multicomponent exercise programs to combat depression after stroke and for the use of stroke education and care support and coordination interventions to address poststroke anxiety. One study provided support for an intensive multidisciplinary home program in improving depression, anxiety, and health-related quality of life. The implications of the findings for practice, research, and education are discussed.

The purpose of this evidence-based review was to search the literature and critically appraise and synthesize the applicable evidence to address the focused question, What is the evidence for the effectiveness of interventions to improve occupational performance for those with psychological and/or emotional impairment after stroke?

Background Literature and Statement of Problem

As many as 50% of stroke survivors may experience a stroke-related psychological or emotional disorder. Carota and Bogousslavsky (2009) placed these disorders in the following categories: (1) affective and mood disorders such as depression, poststroke emotionalism, and generalized anxiety disorders; (2) behavioral and personality changes such as anger, irritability, apathy, sexual changes, and obsessive–compulsive disorder; (3) cognitive and behavioral disintegration such as acute confusional state and delirium; and (4) perception–identity disorders of the self or of other people and places.

Between 35% and 50% of stroke survivors develop depression, the most common psychological sequela of stroke (Barker-Collo, 2007; Go et al., 2013). Risk factors for development of poststroke depression are hypothesized to be either biological, a result of neurological damage, or psychosocial, a result of coping with a life-threatening event. However, the origin of poststroke depression is widely accepted as multifactorial (Whyte & Mulsant, 2002). The highest prevalence of depression occurs from 3 to 6 mo after stroke, but it remains high even as long as 3 yr later (Barker-Collo, 2007; Whyte & Mulsant, 2002). Poststroke depression impedes rehabilitation, impairs physical and cognitive function, increases stress on caregivers, increases the stroke survivor’s risk of death and suicide, increases use of drugs and alcohol, increases use of health resources, and predicts poor compliance with treatment of comorbidities (Hackett, Anderson, House, & Halteh, 2008; Lenze et al., 2004; Whyte, Mulsant, Rovner, & Reynolds, 2006). In spite of its devastating effects, depression is often underdiagnosed and undertreated (Miller et al., 2010). Prevention and treatment of poststroke depression typically consists of administration of antidepressant medications and psychotherapy. Yet, there is mixed evidence for the efficacy of both types of intervention and concern about the side effects of these medications for older adults (Miller et al., 2010).

The prevalence of poststroke anxiety has been estimated to range from 20% to 36%, with length of time after stroke leading to findings of different prevalence levels (Bergersen, Frøslie, Stibrant Sunnerhagen, & Schanke, 2010; Burton et al., 2011). Comparable to depression after stroke, anxiety often goes undertreated. It reduces participation in activities of daily living (ADLs), results in poorer physical and social outcomes, increases caregiver burden, and increases health care costs (Bergersen et al., 2010; Gurr & Muelenz, 2011). When a person is diagnosed with anxiety, pharmaceutical therapy and psychotherapy are the first treatment options (Burton et al., 2011).

Other stroke-related psychological impairments such as irritability, aggressiveness, apathy, poststroke emotionalism, and sexual dysfunction are reported to occur in 20%–50% of stroke survivors, but these conditions are often difficult to distinguish from symptoms of depression or anxiety (Carota & Bogousslavsky, 2009). Perception–identity disorders of the self are typically associated with unilateral spatial neglect and, for the purposes of this review, are considered cognitive disorders. Carota and Bogousslavsky (2009) stated that other psychological impairments (e.g., obsessive–compulsive disorder, confusional state) occur after stroke but are rare.

Intervention with stroke survivors is an important area of practice for occupational therapists in many settings. In contrast to other health care professionals, occupational therapists have training in assessing and treating both psychological and physical impairments to improve occupational performance, thus making their role in stroke rehabilitation vital. With the increasing number of people who have had a stroke and may develop psychological impairments as a consequence, identifying evidence-based interventions within the scope of occupational therapy practice is imperative.

Method for Conducting the Evidence-Based Review

This evidence-based review was completed in collaboration with the American Occupational Therapy Association (AOTA) as part of an evidence-based review project on interventions for adults with stroke. The focused question addressed here was, What is the evidence for the effectiveness of interventions to improve occupational performance for those with psychological and/or emotional impairment after stroke? Arbesman, Lieberman, and Berlanstein (2015) provide a detailed description of the methodology used in the evidence-based reviews, which can be found in their article “Method for the Evidence-Based Reviews on Occupational Therapy and Stroke” in this issue. Supplemental Table 1 summarizes selected articles on interventions that address psychological and emotional impairments after stroke (available online at http://otjournal.net; navigate to this article, and click on “Supplemental”). Complete evidence tables are available in Occupational Therapy Practice Guidelines for Adults With Stroke (Wolf & Nilsen, 2015).

Results

Abstracts of 2,261 articles were retrieved from Medline, PsycINFO, CINAHL, OTseeker, Ageline, the Cochrane Database of Systematic Reviews, DARE, and databases and abstracts found through hand searches of journals and bibliographies. Of those, 39 articles describing 38 studies were included in this review. (Two articles reported results of 1 study at different times postintervention: Ellis, Rodger, McAlpine, & Langhorne, 2005, and McManus, Craig, McAlpine, Langhorne, & Ellis, 2009 .) Evidence provided by the studies was Level I (n = 37), Level II (n = 1), and Level III (n = 1). I then abstracted articles using the evidence table format and summarized them in a Critically Appraised Topic format (Hildebrand, 2014). They were divided into six themes according to type of intervention: (1) exercise or movement based, (2) behavioral therapy and stroke education, (3) behavioral therapy only, (4) stroke education only, (5) care support and coordination, and (6) community-based interventions that included occupational therapy. A summary of each theme is presented here.

Exercise- or Movement-Based Interventions

Fifteen original research articles were analyzed that included exercise or movement interventions and outcomes measures for depression, anxiety, or mental health–related quality of life (HRQOL). Thirteen articles provided Level I evidence; 1, Level II evidence; and 1, Level III evidence. The articles were further divided into two subgroups: single-component exercise or movement programs and multicomponent exercise programs, including a combination of strengthening, endurance, balance, or range-of-motion exercises. I use the term exercise here to describe these interventions.

Single-Component Exercise Programs.

Eight Level I studies included interventions using one type of exercise only. They included very early mobilization, passive range of motion (PROM), bilateral upper-extremity tasks, ergometry, progressive resistive exercises, tai chi, and treadmill walking (Cumming, Collier, Thrift, & Bernhardt, 2008; Lennon, Carey, Gaffney, Stephenson, & Blake, 2008; Morris et al., 2008; Ouellette et al., 2004; Sims et al., 2009; Smith & Thompson, 2008; Taylor-Piliae & Coull, 2012; Tseng, Chen, Wu, & Lin, 2007). Two single-component exercise interventions, very early mobilization in acute care and a PROM intervention in long-term care facilities, were found to reduce incidence of depression or anxiety in the intervention group (IG) compared with the control group (CG; Cumming et al., 2008; Tseng et al., 2007). However, the reduction in depression and anxiety was not maintained after the interventions ended. The results of the PROM intervention may be questioned because of the small sample size and lack of additional attention to the control group.

The six single-component exercise studies using protocols of bilateral upper-extremity tasks, ergometry, progressive resistance training, tai chi, or treadmill walking found no significant differences between groups on mental HRQOL, anxiety, or depression (Lennon et al., 2008; Morris et al., 2008; Ouellette et al., 2004; Sims et al., 2009; Smith & Thompson, 2008; Taylor-Piliae & Coull, 2012). They also reported sample sizes that were too small to determine significant differences between groups. Therefore, from the results of the 8 studies considered here, the evidence is insufficient to support or refute the efficacy of providing single-component exercise interventions to improve depression, anxiety, or mental HRQOL after stroke.

Multicomponent Exercise Programs.

Seven studies combining strengthening, balance, range of motion, or endurance exercises in outpatient, in-home, or community settings measured the effects on mental HRQOL, depression, and anxiety (Level I—Holmgren, Gosman-Hedström, Lindström, & Wester, 2010; Lai et al., 2006; Langhammer, Stanghelle, & Lindmark, 2008; Mead et al., 2007; Olney et al., 2006; Level II—Stuart et al., 2009; Level III—Rand, Eng, Liu-Ambrose, & Tawashy, 2010). Two Level I outpatient multicomponent exercise interventions demonstrated significant differences in depression scores and mental HRQOL in favor of the IG ≤3 mo after the intervention (Lai et al., 2006; Olney et al., 2006). However, significant differences were not maintained at follow-up assessments between 6 and 12 mo after the interventions were completed. Three Level I studies found no significant differences between the IG and CG after intensive exercise programs involving strength, endurance, and balance training (Holmgren et al., 2010; Langhammer et al., 2008; Mead et al., 2007).

A Level II study of a community-based exercise group found that a small subgroup of those who had depressive symptoms at study onset improved significantly on a depression measure compared with those in the CG group who also had depressive symptoms at study onset (Stuart et al., 2009). Conversely, a Level III pilot study found no significant changes for a community-based exercise group in pre- and posttest depression scores (Rand et al., 2010). Although 3 multicomponent exercise interventions demonstrated efficacy in decreasing depression or increasing mental HRQOL (Lai et al., 2006; Olney et al., 2006; Stuart et al., 2009), an important limitation may include the additional attention and social interaction the IG received.

In addition, Stuart et al. (2009) reported depression changes in small participant subgroups, but not for all participants. Four studies in the multicomponent exercise intervention subcategory found no significant differences between groups (Holmgren et al., 2010; Langhammer et al., 2008; Mead et al., 2007; Rand et al., 2010). Therefore, the efficacy of multicomponent exercise programs is inconsistent across studies. An important result of exercise interventions to note is that even if scores improved, the differences between the IG and CG were not maintained after the exercise intervention had ended.

Behavioral Therapy and Stroke Education

Five Level I studies described in 6 articles were included in the category of interventions with both behavioral therapies and stroke education (Chang, Zhang, Xia, & Chen, 2011; Clark, Rubenach, & Winsor, 2003; Ellis et al., 2005; Johnston et al., 2007; Kendall et al., 2007; McManus et al., 2009). Four studies, described in 5 articles, implemented behavior modification or behavior change counseling and stroke-specific education on discharge and shortly after discharge from the hospital (Clark et al., 2003; Ellis et al., 2005; Johnston et al., 2007; Kendall et al., 2007; McManus et al., 2009). No significant differences were found between groups on depression, anxiety, or mental HRQOL measures. In an inpatient rehabilitation facility, Chang et al. (2011) implemented behavioral therapy and stroke education and found that the IG had statistically significant improvements in anxiety, depression, and mental HRQOL compared with the CG. From the results of the 5 studies considered here, the evidence is insufficient to support or refute the efficacy of providing these types of behavioral therapies in combination with stroke education to treat depression or anxiety or improve mental HRQOL in people after stroke.

Behavioral Therapy Only

Five Level I studies implemented behavioral therapy–only interventions (Davis, 2004; Lincoln & Flannaghan, 2003; Mitchell et al., 2009; Robinson et al., 2008; Watkins et al., 2007). Problem-solving therapy was used in 2 well-conducted randomized controlled trials (RCTs) with statistically significant improvement in depression scores for the IG (Mitchell et al., 2009; Robinson et al., 2008). In another well-conducted RCT, motivational interviewing was found to be effective in improving depression and mental HRQOL (Watkins et al., 2007). Cognitive–behavioral therapy was not found to provide significant improvement on depression measures when compared with an attention placebo group and a group with no intervention (Lincoln & Flannaghan, 2003). Finally, in a very small pilot study of life review therapy, Davis (2004) reported significant differences between the IG and the CG on a depression measure. However, because the study was inadequately powered, life review therapy requires further research to determine its effect with this population (Davis, 2004). These results provide some support for problem-solving therapy and motivational interviewing to treat depression after stroke.

Stroke Education Only

Two Level I studies implemented stroke education only with people poststroke in inpatient rehabilitation (Hoffmann, McKenna, Worrall, & Read, 2007; Smith, Forster, & Young, 2004) and found conflicting evidence. Smith et al. (2004) found that the IG had significantly better anxiety scores, but Hoffman et al. (2007) reported that the CG had significantly less anxiety than the IG. These authors found no difference between groups on depression scores. On the basis of these 2 studies, the evidence for stroke education in the treatment of anxiety is mixed and is not sufficient to support or refute its use in treatment of depression.

Care Support and Coordination

Six Level I studies used care support and coordination beginning just before or immediately on discharge from the hospital and consisting of a combination of face-to-face meetings, home visits, and telephone contacts (Boter, 2004; Burton & Gibbon, 2005; Claiborne, 2006; Lincoln, Francis, Lilley, Sharma, & Summerfield, 2003; Mayo et al., 2008; Tilling, Coshall, McKevitt, Daneski, & Wolfe, 2005). Three studies found a significant difference between groups on anxiety scores (Boter, 2004), emotional distress (Burton & Gibbon, 2005), and mental HRQOL and depression (Claiborne, 2006). However, Lincoln et al. (2003), Tilling et al. (2005), and Mayo et al. (2008) found no significant differences between groups in improving anxiety, depression, or mental HRQOL. Thus, the evidence for care support and coordination is inconsistent.

Community-Based Interventions That Included Occupational Therapy

Five Level I studies included occupational therapy as the primary discipline delivering a community-based intervention, as a part of a multidisciplinary team in home health, or as researchers evaluating a day program (Corr, Phillips, & Walker, 2004; Desrosiers et al., 2007; Egan, Kessler, Laporte, Metcalfe, & Carter, 2007; Logan et al., 2004; Ryan, Enderby, & Rigby, 2006). An intensive multidisciplinary intervention (defined as six or more home health visits) showed significant differences for the IG in mental HRQOL, depression, and anxiety (Ryan et al., 2006). An occupational therapy–directed program with intervention by an occupational therapist and a recreation therapist addressing leisure activities in the community was found to improve depression but not mental HRQOL scores (Desrosiers et al., 2007).

The other 3 studies—1 on an occupational therapist–led community occupation-based treatment approach (Egan et al., 2007), 1 on a community mobility intervention (Logan et al., 2004), and 1 on a day service pilot program for younger adults (Corr et al., 2004)—did not show significant differences in mental HRQOL, anxiety, or depression between groups. Therefore, there is some support for implementation of more intensive home health that includes occupational therapy (Ryan et al., 2006) and for a community occupational therapy–led leisure activity program (Desrosiers et al., 2007). However, there is not enough evidence to support or refute the efficacy of the other community-based interventions that included occupational therapy.

Discussion and Implications for Practice, Education, and Research

The purpose of this evidence-based review was to examine the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve occupational performance of those with psychological or emotional impairment after stroke. Although most of the studies reviewed were not implemented by occupational therapists, the intervention themes fall within occupational therapy’s scope of practice as outlined by the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; AOTA, 2014).

This evidence-based review yielded 39 articles describing 38 interventions for depression, anxiety, and mental HRQOL poststroke. No Level I, II, or III studies were found for treatment of other psychological sequelae of stroke. Although literature exists for treatment of these conditions, it did not meet the inclusion criteria for this review. The evidence from the studies was wide ranging and diverse, but it provides guidance to occupational therapists in implementing best practices for clients with depression, anxiety, or decreased mental HRQOL poststroke.

Implications for Practice

In practice, mental health may be a specialty area for some occupational therapists working in settings that primarily address psychological factors. However, occupational therapists in all rehabilitation settings in which clients with stroke will be served must be prepared to assess and treat mental health impairments so that stroke survivors may fully participate in and receive the maximum benefit of rehabilitation. This must be fundamental to occupational therapists’ services to stroke survivors.

The largest number of studies in this evidence-based review analyzed treatment effects of exercise on depression, anxiety, or mental HRQOL. The Framework (AOTA, 2014) states that occupational therapists use exercise to prepare for or in conjunction with occupations and activities. However, the studies cited here examined the effects of exercise-only interventions. Although single-component exercise programs may provide other benefits to people after stroke, little evidence was found for their efficacy in treating psychological impairments. Multicomponent exercise interventions showed more promise in that 3 studies demonstrated efficacy in improving depression or mental HRQOL (Lai et al., 2006; Olney et al., 2006; Stuart et al., 2009). Although exercise has been shown to be an effective intervention in management of depression (Rimer et al., 2012), one may not automatically assume that exercise will be effective for preventing or treating depression after stroke. Additionally, these studies did not examine the effect of exercise as a preparatory method within an occupation-based intervention approach.

Support for the effectiveness of treatment of depression was found for problem-solving techniques and motivational interviewing (Mitchell et al., 2009; Robinson et al., 2008; Watkins et al., 2007). Both behavioral therapy techniques are emerging in occupational therapy educational literature, but today’s practitioners may not have been introduced to them (Brown & Stoffel, 2011). Further training in these techniques is recommended when working with this population.

Anxiety was reduced after one stroke education program and two care support and coordination interventions (Boter, 2004; Burton & Gibbon, 2005; Smith et al., 2004). Occupational therapists are well suited to provide education in all aspects of stroke and are an essential part of the multidisciplinary team in follow-up services postdischarge. Preparing clients for function in the home and community is fundamental to occupational therapy practice.

Finally, because evidence has shown that more home health visits to people with stroke may improve their mental HRQOL, depression, and anxiety, occupational therapists should recommend more visits and advocate for them (Ryan et al., 2006). Occupational therapists in home health and community practice should address not only basic ADLs but also leisure activities for improving depression among stroke survivors (Desrosiers et al., 2007).

Implications for Education

It is essential that educational programs recognize that rehabilitation with people poststroke includes psychological interventions, not just interventions addressing physical impairments. The Accreditation Council for Occupational Therapy Education has recognized the importance of psychological factors for occupational therapy clients in its requirements; that is, all programs will include course work that will enable practitioners to understand human behavior and support quality of life in promotion of both physical and mental health (AOTA, 2012). This requirement necessitates that students study psychology, and many complete fieldwork in settings that address psychological factors. These courses should include problem-solving therapy and motivational interviewing techniques with case examples of people who have experienced stroke or other disabling health conditions.

Implications for Research

Occupational therapy interventions are complex and multifaceted. This is particularly apparent in treatment of psychological impairments resulting from stroke. Thus, in future development of evidence-based interventions, occupational therapy protocols must be clearly defined, and treatment fidelity must be measured. A clearly defined intervention protocol will allow comparison and replication of studies, and measurement of intervention therapists’ treatment fidelity will ensure that the results are attributable to the intervention and not to confounding factors or therapists’ skill (Hildebrand et al., 2012). Additionally, future research must take into consideration study participants’ heterogeneity when developing inclusion criteria (e.g., age, length of time since stroke, treatment setting, stroke severity). Interventions that are successful in one group or setting may not be translatable to all others. It is also crucial that researchers include people with aphasia or cognitive deficits because they are at high risk for experiencing anxiety and depression after stroke.

Occupational therapists are uniquely qualified health professionals who can address both the physical and the psychological impairments caused by stroke. However, many of the studies in this evidence-based review did not include occupational therapists. Future research must examine occupational therapy interventions for psychological impairments after stroke that are within occupational therapy’s scope of practice and focused on occupation. Finally, the interventions found through this evidence-based review should be systematically reviewed to further determine whether they are efficacious in the prevention or treatment of depression, anxiety, or decreased mental HRQOL after stroke.

Limitations

The results of this evidence-based review must be interpreted cautiously because of several limitations of the studies. A majority of studies, 25, had too few participants and were not powered enough to determine significant differences between IGs and CGs. Thirty-one studies did not provide equivalent attention to the CG participants, which is an essential component when measuring depression, anxiety, or mental HRQOL. Only 3 of 10 studies using behavioral therapy and education or behavioral therapy reported on the training, supervision, and treatment fidelity of their interventionists. Reporting on these areas is critical in the psychotherapy fields for interventions to be considered evidence based (Hildebrand et al., 2012). Finally, many of the studies were not dedicated to preventing or alleviating depression or anxiety, particularly the exercise interventions, but researchers measured these as secondary outcomes.

Conclusion

This evidence-based review provides some guidance, but more research is required to ascertain what interventions are effective for people with psychological impairments after stroke. The prevalence of these impairments compels us to focus on the importance of mental health assessment and treatment in occupational therapy education, practice, and research and provides an important opportunity to demonstrate our unique skills for assessing and treating both the physical and the psychological impairments resulting from stroke.

Acknowledgments

I gratefully acknowledge the contribution of Sarah Timmons, who completed many Critically Appraised Paper reviews and drafts of evidence tables while an occupational therapy master’s degree student at East Carolina University. I gratefully acknowledge the guidance and support received from Deborah Lieberman and Marion Arbesman during the article selection, review, and evidence table and Critically Appraised Topic development process.

^*Indicates studies included in this review.

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